Retention suture device and method

ABSTRACT

A retention suture is looped around an incision in a deep tissue layer such as the muscle layer, with the ends of the suture being passed up through a tubular retention suture device. The device is emplaced in the incision and the ends of the retention suture are drawn up tightly and secured at the top end of the device. The incision is closed between the retention suture devices by the primary wound closure sutures, and these devices remain in the incision until healing of the muscle tissue layer is adequate.

United States Patent 1191 Smith 1 Nov. 5, 1974 i 1 RETENTION SUTURE DEVICE AND METHOD [76] Inventor: Dean 13. Smith, 20 S. Park St.,

Madison, Wis. 53715 [22] Filed: Sept. 17, 1973 [21] Appl. No.: 397,878

[52] US. Cl. 128/335, 128/335.5

[51] llnt. Cl A6lb 17/04 {58] Field of Search 128/334 R, 335, 335.5, 128/336, 337, 339

[56] References Cited UNlTED STATES PATENTS 2,075,508 3/1937 Davidson 128/335 3,625,220 12/1971 Engelsher 1 i 128/335 3,695,271 10/1972 Chodorow 128/335 FOREIGN PATENTS OR APPLICATIONS 494,960 6/1919 France 128/335 116594 6/1946 Sweden 128/334 R Primary Examiner-Lucie 1-1. Laudenslager Attorney, Agent, or Firm-Theodore J. Long; John M. Winter; Harry C. Engstrom [57] ABSTRACT A retention suture is looped around an incision in a deep tissue layer such as the muscle layer, with the ends of the suture being passed up through a tubular retention suture device. The device: is emplaced in the incision and the ends of the retention suture are drawn up tightly and secured at the top end of the device. The incision is closed between the retention suture devices by the primary wound closure sutures, and these devices remain in the incision until healing of the mus cle tissue layer is adequate.

9 Claims, 11 Drawing Figures BACKGROUND OF THE INVENTION 1. Field of the Invention This invention pertains to methods of placing retention sutures around an incision, and devices used to facilitate the placement of retention sutures.

2. Description of the Prior Art It is common practice in abdominal surgery to employ retention sutures which support the primary wound closure by absorbing lateral tension exerted on the several tissue layers in which an incision has been made. The basic purpose of the retention sutures is to absorb the lateral tension placed on the deeper tissue layers of muscle and fascia since the strength of the primary incision closures in these deeper layers may not be adequate to withstand the strain on the incision. The sutures used in the primary incision closure in deeper tissue layers are often made of absorbable suture material, which contributes to the doubtful strength of the closure.

Retention sutures are usually made of nonabsorbable suture material such as silk, cotton, or synthetic fibers. Very heavy absorbable suture material is inappropriate for use as a retention suture because of the questionable strength of this material, and becuase of the marked tissue reaction that would occur with such a large amount of absorbable suture being present. The use of nonabsorbable retention sutures requires that they be removed when healing of the wound is satisfactory, usually in two to three weeks. To facilitate the removal of the suture, the common surgical practice has been to pass the suture downwardly through the skin at a point spaced several centimeters laterally from the incision, and continue the passage of the suture through the fat layer, fascia, muscle layer and the peritoneum. The suture is then brought to a point spaced laterally away from the incision of the other side thereof, and is passed up through the peritoneum and the respective tissue layers to protrude from the skin. The retention suture, having thus been looped around the incision in all tissue layers, is tied tightly to draw the tissue layers together. When healing is adequate, and the retention suture is to be removed, the suture is simply lifted up, cut, and pulled out. Because sutures placed by this technique have to be tied quite tightly to apply the proper tension at the lateral aspect of the incision, they frequently will cut into the skin, possibly producing necrosis, or at the minimum, cross hatching of the skin. Distortion and compartmentalization of the subcutaneous tissues often occurs, promoting the development of serous fluid collections and secondary infections.

Several devices have been developed in attempts to mitigate the problems associated with the usual retention suture technique described above. A common device is a piece of hollow tubing through which the suture is passed, which is placed transversely across the incision, and which is intended to distribute the pressure of the suture over a greater skin area. However, these tubes, which may be telescoping, do not adequately protect the skin if the suture is tied tightly. Various retention suture bridges have been developed which are made of rigid material, and which support the suture above the skin between the two exit points of the suture. These bridges tend to be cumbersome and complicate the nursing care of the patient. They may also produce some degree of pressure injury to the skin where the feet of the apparatus are placed. Since all of these devices are used with the usual retention suture technique, the suture is still being brought through the fat layers and the skin, even though the main purpose of the retention suture is to support the deeper layers of abdominal wall tissue that are primarily subject to stress. The passage of the suture material through the subcutaneous tissue and skin facilitates the removal of the suture, but does not serve any other substantial purpose.

SUMMARY OF THE INVENTION I have invented a method of placing retention sutures in a deep tissue layer without passing the ends of the suture through the subcutaneous tissue and across the skin. I have also invented a device which enables the placement of a retention suture in this manner.

A retention suture is first looped around an incision in only the layers of muscle, fascia, and peritoneum. The end portions of the suture are passed up through a tubular portion of my retention suture device. This tube portion is inserted into the incision so that the bottom end of the tube portion is adjacent to the upper surface of the tissue layer being sutured. The end portions of the retention suture are drawn up tightly and tied or otherwise joined over a portion of the retention suture device, thus preventing retraction of the suture into the device.

In different embodiments of my invention the portion of the device over which the suture is tied may consist of an element or spindle affixed across the top end of the tube portion, or a removable support member which is placed transversely across the top end. The bottom end of the tube portion may also be flared out, either in two opposing directions or around its entire circumference, to thereby allow the suture to be drawn into the tube portion with minimal friction. The several retention sutures thus placed around the incision in deep layers of tissue are capable of absorbing the lateral tension applied to those tissue layers, thereby relieving the primary wound closure of this tension.

The incision in the subcutaneous tissue layer and skin is closed by the primary wound closure sutures at all points along the incision except where the retention suture devices are located, and these devices remain in the incision until healing of the tissue layer having the retention sutures is adequate. The retention sutures are then cut and pulled out and the retention suture devices are removed. Clinical experience has shown that the areas where the retention suture devices were emplaced heal rapidly and leave very little scarring. In addition, when this method of placing; retention sutures is utilized, the possibility of skin damage and infection is greatly reduced since the retention suture does not have to be passed through the skin and higher subcutaneos tissue layers. It has also been demonstrated that the use of my retention suture devices has been more comfortable for the patient and less cumbersome than devices intended for use with conventionally placed retention sutures.

BRIEF DESCRIPTION OF THE DRAWING In the drawing:

FIG. 1 is a front elevation view showing a preferred embodiment of a retention suture device exemplifying the principles of my invention.

FIG. 2 is a side elevation view of the retention suture device shown in FIG. 1.

FIG. 3 is a side cross-sectional view of the retention suture device shown in FIG. 1.

FIG. 4 is a side cross-sectional view of a modified embodiment of the device of FIG. 1.

FIG. 5 is a top view of the device of FIG. 1, shown emplaced in an incision.

FIG. 6 is a cross-sectional view taken along the line 66 of FIG. 5, showing the placement of the device of FIG. 1 in an incision.

FIG. 7 is a front elevation view of another emobdiment of a retention suture device.

FIG. 8 is a front elevation view of a modified embodiment of the retention suture device of FIG. 7.

FIG. 9 is a side elevation view of the vertical tube portion of the retention suture device of FIG. 8.

FIG. 10 is a top view of the device of FIG. 8, shown emplaced in an incision.

FIG. 11 is a cross-sectional view taken along the line 1111 of FIG. 10, showing the placement of the device of FIG. 8 in an incision.

DESCRIPTION OF THE PREFERRED EMBODIMENTS Referring now more particularly to the drawing, wherein like numerals refer to like parts throughout the several views, a preferred embodiment of my retention suture device is shown generally at in FIGS. 1-3.

The retention suture device 20 has a generally cylindrical hollow tube portion 21, a top end 22 which is flared out around its circumference, and a bottom end 23 which is flared out in two opposed directions to form curved flanges or reception portions 230 for s suture. As best shown in FIG. 3, the two curved reception portions 23a provide a smooth rounded edge for the two end portions of a suture to be drawn over when the device 20 is emplaced in an incision. A dividing wall 24 runs substantially the length of the tube 21 and divides the bore of the tube into two passageways each large enough to allow a standard retention suture to be passed therethrough. The dividing wall 24 supports a rounded spindle element 25 located at the top end 22 of the device 20, which, as best shown in FIG. 1, is slightly bowed towards the middle of the element.

A modified embodiment of the retention suture device 20 is shown generally at 26 in FIG. 4. The device 26 has a hollow tube portion 27, a flared top end 28, and a bottom end 29 which is flared out in two opposing directions to form suture reception portions 29a in the same manner as described for the device 20. The retention suture device 26 does not have a dividing wall, but does have a rounded element or bar 30 narrower than the diameter of the bore of the tube 27, which is affixed across the top end 28 of the device.

The use of the retention suture device 20 in placing a retention suture is best illustrated with reference to FIGS. 5 and 6. An incision 31 is made surgically in the skin 32 and through a fat layer 33 and a deep muscle layer 34. Depending on the surgical technique employed, the retention suture may or may not traverse the peritioneal cavity throughout its passage. The muscle and fascial layers 34 are shown schematically in FIG. 6 as a single layer for illustrative purposes, and

this is intended to represent any combination of layers of body tissue, or portions of a single layer of body tissue, which a retention suture might be placed around.

When using my retention suture device 20, a retention suture 35 is passed down through only the muscle and fascial layers 34 on one side of the incision 31, and is brought up through the layers onthe other side of the incision. Thus the retention suture 35 is looped around the incision 31 only in the muscle and fascia] layers 34 in contrast to the usual retention suture technique. The end portions 35a and 35b of the suture 35 are then brought up through the incision 31 and laid aside while the primary incision closure is made on the muscle and fascial layers 34. When the primary incision closure has been completed in the muscle and fascial layers, the suture end portions 35a and 35b are passed up from the bottom end 23 to the top end 22 of the suture device 20 on opposite sides of the dividing wall 24. The dividing wall 24 allows the suture end portions to be more easily passed through the tube 21 by the surgeon, and ensures that the end portions will not become twisted or otherwise entangled. The suture-device 20- is then inserted into the incision and positioned as shown in FIG. 6 so that the two end portions of the suture are in contact with the curved reception portions 23a. The curvature of these reception portions allows the suture to be pulled over them with minimal friction and little chance of damage to the suture.

The device '20 is held in place in the incision 31 while the end portions 35a and 35b of the suture are drawn up tightly and tied in a knot 36 over the spindle element 25. The slight bow in the element 25 prevents the tied end portions of the suture from slipping off the end of the spindle element, and the end portions of the suture are thus retained above the top end 22 by the spindle element. The suture 35 is now capable of absorbing the lateral tension applied to the muscle and fascial layers 34, thus relieving the primary wound closure at the incision 31 of this tension. The length of the tube 21 is chosen to correspond to the distance between the skin 32 and the upper surface of the muscle and fascial layers 34 of the patient being operated on. With the bottom end 23 adjacent to the muscle and fascial layer, the top end 22 should protrude slightly above the skin to facilitate removal of the suture.

Several retention sutures must usually be placed around a typical abdominal incision, with the number of sutures and therefore suture devices required depending on the length of the incision. After all of the sutures have been placed, the incision in the subcutaneous tissue layers 33 and the skin 32 is closed by primary wound closure sutures at all points except where the retention suture devices 20 are located. When healing of the muscle and fascial tissue layers 34 is adequate, the retention sutures 35 are cut and pulled out. The retention suture devices 20 should be held firmly in place in the incision with the bottom ends 23 just above the muscle and fascial layers, to allow the sutures to be pulled out through the devices without damage to the subcutaneous tissue. Experience has shown that following the removal of the sutures 35, the retention suture devices 20 can be easily removed, leaving narrow tracts which are lined with granulation tissue. These tracts close rapidly in a few days, with only minimal attention to the wound required to prevent pocketing of serum in the tracts. The closure of the skin over these tracts is usally so satisfactory that it is difficult to identify the exit points of the retention suture devices in a few weeks.

The modified retention suture device 26 shown in FIG. 4 is utilized in the same manner as described above for the device 2t}, except that the suture end portions are tied over and retained by the bar 30. The ab sence of the dividing wall in this device allows some twisting of the suture end portions, but this is not a serious problem if the length of the tube 27 is relatively short.

An alternative embodiment of a retention suture device is shown generally at 37 in FIG. 7. The device 37 has a hollow tube 38 with a top end 39 and a bottom end 4t) which are both flared out around their circum' ferences. A support member 4i is placed transversely over the top end 39 of the tube 38 when the device 37 is being used with a retention suture. The tube 38 is emplaced in an incision as described above for the device 20, with the ends of the suture being brought up through the bore of the tube and tied over the support member M. The support member may be tubular or solid, and preferably has flared ends 41a and 41b, as shown in FIG. 7. to prevent the tied suture from slipping off the ends of the support member.

A modified embodiment of the device 37 is shown generally at 42 in FIG. 8. The retention suture device 42 has a hollow tube 43 which has a top end 44 with flared portions 44a which extend from the tube in two opposed directions, and grooved portions 4417 which are substantially at right angles to the flared portions. The bottom end 45 of the tube is flared out around its circumference to provide a curved edge for a suture to be drawn over. The retention suture device 42 also has a support member 46., which may be hollow or solid and has flared ends 46a and 46b, and which fits into the grooves 44b and is thus laterally restrained in this position by the top end flared portions 44a.

Placement of a retention suture using the retention suture device 42 is shown in FIGS. and 11, which will serve to illustrate the use of both the device 42 and the device 37. As shown in FIG. ll, a suture 47 is looped around the incision 3ll only in the muscle and fascial layers 34. in the same manner as indicated above wherein the use of the device was described. The end portions 47a and 47b ofthe suture are brought up through the incision 3i and laid aside while the primary incision closure is made on the muscle and fascia] layers 34. The end portions 47a and 47b of the suture 47 are then passed up through the tube 43 and the tube is inserted into the incision. The support member 46 is placed in the grooves 4417 on the top end 44 of the tube, and the end portions of the suture 47 are drawn up tightly and tied over the support member 46 in a knot 48. The primary closures of the subcutaneous tissue layers and the skin 32 are carried out, and the suture devices 42; remain in the incision until healing is adequate. The tube 43 is removed as described previously for the retention suture device 20, and is similarly chosen to correspond in length to the distance between the upper surface of the muscle layer and the skin of the patient being operated on.

The retention suture devices described above are preferably made of metals or plastics which will not react with body tissues and liquids, and which can be sterilized as is usual with surgical instruments. Al-

though clinical experience has shown that the chance of infection around these devices is slight, the use of a suitable broad spectrum antibiotic ointment, instilled into the bore of the tube portion and around its outer circumference at the skin line, would be a useful adjunct to the surgical technique described.

It is understood that my invention is not confined to the particular construction and arrangement of parts herein illustrated and described, but embraces all such modified forms thereof as come with the scope of the following claims.

I claim:

1. A device insertable in a surgical incision for use with a rentention suture which is looped around an incision in a deep tissue layer comprising:

a. an elongate hollow tube adapted to be inserted into said surgical incision above said deep tissue layer, said tube having a bottom end and a top end, the bore of said tube being sufficiently large to receive the two end portions of said suture therethrough; and

b. means at the top end of said tube for retaining said end portions of said suture and preventing same from being retracted through said tube.

2. The device as specified in claim-l wherein said means for retaining said end portions of said suture comprises an element extending across the bore of said tube at the top end of said tube to allow said end portions of said suture to be tied together over said element.

3. The device as specified in claim 2 wherein said element extends substantially the length of said tube to divide the bore of said tube into two passageways each sufficiently large to receive one end portion of said suture therethrough.

4. The device as specified in claim 1 wherein said means for retaining the end portions of said suture comprises a support member placed transversely over the top end of said tube in position to allow the end portions of said suture to be tied together over said support member.

5. The device as specified in claim 4 wherein the top end of said tube has flared portions in two opposed directions and grooved portions substantially at right angles to said flared portions, said support member fitting into said grooved portions.

6. The device as specified in claim 5 wherein said support member has flared ends.

7. The device as specified in claim 1 wherein the bttom end of said tube is flared out in two opposed directions.

8. The device as specified in claim 1 wherein the bottom end of said tube is flared around the circumference thereof.

9. A method of suturing a surgical incision particularly that portion of said incicsion in deep body tissue comprising the steps of:

a. encircling the suture around said incision in said deep body tissue;

b. passing the end portions of said suture through a hollow tube;

c. inserting said tube into the incision above said deep body tissue; and

d. securing said end portions of said suture at the top 

1. A device insertable in a surgical incision for use with a rentention suture which is looped around an incision in a deep tissue layer comprising: a. an elongate hollow tube adapted to be inserted into said surgical incision above said deep tissue layer, said tube having a bottom end and a top end, the bore of said tube being sufficiently large to receive the two end portions of said suture therethrough; and b. means at the top end of said tube for retaining said end portions of said suture and preventing same from being retracted through said tube.
 2. The device as specified in claim 1 wherein said means for retaining said end portions of said suture comprises an element extending across the bore of said tube at the top end of said tube to allow said end portions of said suture to be tied together over said element.
 3. The device as specified in claim 2 wherein said element extends substantially the length of said tube to divide the bore of said tube into two passageways each sufficiently large to receive one end portion of said suture therethrough.
 4. The device as specified in claim 1 wherein said means for retaining the end portions of said suture comprises a support member placed transversely over the top end of said tube in position to allow the end portions of said suture to be tied together over said support member.
 5. The device as speciFied in claim 4 wherein the top end of said tube has flared portions in two opposed directions and grooved portions substantially at right angles to said flared portions, said support member fitting into said grooved portions.
 6. The device as specified in claim 5 wherein said support member has flared ends.
 7. The device as specified in claim 1 wherein the bttom end of said tube is flared out in two opposed directions.
 8. The device as specified in claim 1 wherein the bottom end of said tube is flared around the circumference thereof.
 9. A method of suturing a surgical incision particularly that portion of said incicsion in deep body tissue comprising the steps of: a. encircling the suture around said incision in said deep body tissue; b. passing the end portions of said suture through a hollow tube; c. inserting said tube into the incision above said deep body tissue; and d. securing said end portions of said suture at the top end of said tube. 